47th DIRECTING COUNCIL 58th SESSION OF THE REGIONAL COMMITTEE

Transcription

1 PAN AMERICAN HEALTH ORGANIZATION WORLD HEALTH ORGANIZATION 47th DIRECTING COUNCIL 58th SESSION OF THE REGIONAL COMMITTEE Washington, D.C., USA, September 2006 Provisional Agenda Item September 2006 ORIGINAL: ENGLISH REGIONAL STRATEGY AND PLAN OF ACTION ON AN INTEGRATED APPROACH TO THE PREVENTION AND CONTROL OF CHRONIC DISEASES, INCLUDING DIET, PHYSICAL ACTIVITY, AND HEALTH In 2002, the 26th Pan American Sanitary Conference recognized chronic noncommunicable diseases as the greatest cause of premature death and morbidity in Latin America and the Caribbean (LAC) and adopted Resolution CSP26.R15, which called for increased and coordinated technical cooperation from PAHO. In response to this resolution and recognizing the need for an updated interprogrammatic chronic disease strategy, PAHO has developed a Regional Strategy and Plan of Action. It notes that chronic diseases are devastating to individuals, families, and communities, particularly poor populations; and they are a growing threat to economic development. In the next two decades in LAC, it is estimated that there will be a near tripling of the incidence of ischemic heart disease and stroke. Moreover, vulnerable populations such as the poor are more likely to develop chronic diseases, and low income families are more likely to become impoverished from them. The societal costs associated with chronic diseases are staggering. For example, the total annual cost associated with diabetes was estimated at US$ 65 billion for LAC in This Regional Strategy has four lines of action that recognize that chronic diseases need to be prioritized in the political and public health agendas; identify surveillance as a key component; recognize that health systems must be reoriented to respond to the needs of people with chronic conditions; and note the essential role of health promotion and disease prevention. The four lines of action are vitally interdependent, inasmuch as one without the other leaves tremendous gaps in reaching all sectors of the population and in achieving the goal of the Regional Strategy to prevent and reduce the burden of chronic diseases and related risk factors in the Americas. Countries are now at a critical juncture. The evidence is clear, and the time has come for comprehensive and integrated action to reverse this deadly epidemic. The Directing Council is requested to consider the annexed resolution proposed by the Executive Committee.

2 Page 2 CONTENTS Page Introduction...4 Process...4 Rationale...5 Situation Analysis...5 Cost Effective Prevention and Management Practices...8 Guiding Principles...9 Framework for Action...10 Strategic Approaches...11 Advocate Policy Changes and Development of Effective Public Policy...11 Build Capacity for Community-based Actions...11 Strengthen Health Services for the Integrated Prevention and Management of Chronic Diseases...12 Reinforce the Competencies of the Health Care Work Force for Chronic Disease Prevention and Management...12 Create Multisectoral Partnerships and Networks for Chronic Disease...13 Build Capacity for Chronic Disease Information Generation and Knowledge Management...13 Plan of Action...14

3 Page 3 CONTENTS (Cont.) Page Lines of Action...14 Public Policy and Advocacy...14 Surveillance...14 Health Promotion and Disease Prevention...15 Integrated Management of Chronic Diseases and Risk Factors...15 Budget for the Regional Strategy...16 Action by the Directing Council...17 References Annexes: Annex A: Action Plan for the Integrated Prevention and Control of Chronic Diseases and Risk Factors Annex B: Resolution CE138.R1

4 Page 4 Introduction 1. Chronic diseases have not received the priority attention in public health policies and programs commensurate with their disease burden in this Region. There are clear evidence and cost-effective interventions available to prevent premature deaths from chronic diseases, and it is time to act to prevent the further loss of millions of lives and damage to economies (1). 2. Every country, regardless of the level of resources can make significant improvements in chronic disease prevention and control. The major causes of chronic diseases are known, and if these risk factors were eliminated, at least 80% of all heart disease, stroke and type 2 diabetes would be prevented; over 40% of cancer would be prevented (1).This Regional Strategy aims to prevent and reduce the burden of chronic diseases and related risk factors in the Americas. It makes the case for urgent action, and is intended to guide PAHO s technical cooperation on chronic diseases and to steer in the development or strengthening of chronic disease national plans and programs. 3. The strategic approaches and lines of action identified in this Regional Strategy are consistent with those in Resolution CSP26.R15, adopted by the Pan American Sanitary Conference in This proposal also incorporates themes from the Global Strategy on Diet, Physical Activity, and Health, which focuses on two of the main chronic disease risk factors. To address the epidemic of chronic diseases in the Region, a long-term, expounded strategy is needed that integrates current practice with new directions and approaches. Process 4. In the past, the major challenges for PAHO s delivery of technical cooperation for chronic disease prevention and control have been the development of an interprogrammatic approach and the integration of activities across relevant PAHO technical offices, along with maximizing external partnerships to efficiently use the scarce resources available in the Region. For these reasons, the process to develop the Regional Strategy has been participatory and inclusive, involving all related PAHO technical units and country offices, and seeking input from a wide range of external stakeholders, including representatives from the health ministries, nongovernmental organizations (NGOs), universities, professional associations, and local governments. Country and subregional consultations were held and contributions were received from over 190 participants from 26 countries in the Region.

5 Page 5 Rationale 5. A strategy is required to address the fact that the prevalence of all leading chronic diseases is increasing, with the majority occurring in developing countries, and are forecast to increase substantially over the next two decades (2). The Region of the Americas has one of the highest mortality rates from diabetes mellitus of all WHO Regions (3). In addition, there are significant socioeconomic inequities in the Region, resulting in a higher chronic disease burden and mortality among poorer people, leading to a cycle of deprivation and ill health (4). This Region is characterized by wellestablished health systems and advances in primary health care which can be better oriented to address chronic conditions. For these reasons, a Regional Strategy is proposed which is appropriate to the cultural and socioeconomic circumstances of the Americas, and incorporates strategic approaches and actions suitable to this Region. 6. In addition, it is recognized that intersectoral collaboration outside the health sector is required to achieve a meaningful impact on chronic diseases. Poverty, unhealthy environmental conditions, and low education are factors that contribute to chronic disease occurrence and are influenced by the geopolitical and economic situation. Moreover, chronic disease risk factors such as unhealthy diets and physical inactivity are affected by sectors such as agriculture, transport, and trade. Therefore, a Regional Strategy is required which addresses this need for comprehensive and integrated action with sectors outside of the traditional health sector. Situation Analysis 7. The epidemic of chronic diseases threatens economic and social development, and the lives and health of millions of people. In 2005, an estimated 35 million people worldwide died from chronic diseases; this is double the number of deaths from all infectious diseases (including HIV/AIDS, malaria, and tuberculosis), maternal and perinatal conditions, and nutritional deficiencies combined (1). While deaths from infectious diseases, perinatal conditions, and nutritional deficiencies are expected to decline by 3% over the next 10 years, deaths due to chronic diseases are projected to increase by 17% by 2015 (1). 8. In LAC, chronic diseases are now the leading cause of premature mortality and disability in the vast majority of countries. In 2002, they accounted for 44% of deaths among men and women below the age of 70 years, and were responsible for two out of three deaths in the total population (5). Chronic diseases contributed to almost 50% of disability-adjusted life years lost in the Region (5). The chronic disease burden may be even greater than these statistics indicate, given the large proportion of underreporting in mortality data in the Region. The most commonly occurring chronic diseases and those

6 Page 6 of greatest public health importance in the Region are: cardiovascular disease including hypertension, cancer, chronic respiratory diseases, and diabetes. 9. In the first decade of the 21st century, cardiovascular diseases are expected to claim some 20.7 million lives in the Region (4). In 2005 in LAC, 31% of all deaths were attributable to cardiovascular diseases (4). Predictions for the next two decades include a near tripling of ischemic heart disease and stroke mortality in Latin America (2). 10. Hypertension is one of the most important risk factors for heart disease and affects between 8% and 30% of the Region s populations (4). Mexico, one of the few countries that has conducted more than one chronic-disease risk-factor survey, found that the prevalence of hypertension had increased from 26% in 1993 to 30% in 2000 (6). 11. Cancer accounts for 20% of chronic disease mortality, and in 2002 there were an estimated 459,000 deaths due to cancer (7). This represents a 33% increase since 1990 in the Region. The World Health Organization (WHO) estimates that by 2020, there will be 833,800 deaths due to cancer in LAC (7). 12. Thirty-five million people in the Region are currently affected by diabetes, and WHO forecasts an increase to 64 million by 2025 (8). It is estimated that in 2003, diabetes was related to some 300,000 deaths in Latin America and the Caribbean, although official statistics link only some 70,000 deaths to the disease, annually. Additionally, the societal costs of diabetes were estimated at $65 billion in 2000 (8). 13. The nutrition transition in our Region is characterized by a low consumption of fruits, vegetables, whole grains, cereals, and legumes. This is coupled with a relatively high consumption of foods rich in saturated fat, sugars and salt, among them milk, meats, refined cereals, and processed foods. This dietary pattern is a key factor leading to a rise in the prevalent overweight and obesity. Population-based surveys from LAC show that, in 2002, 50% to 60% of adults and 7% to 12% of children less than 5 years of age were overweight or obese (9). In Chile and Mexico, the 2004 national surveys showed that 15% of adolescents were obese (9). The prevalence of overweight among adults is 45% and 65% in Canada (10) and the United States of America (11), respectively. 14. Furthermore, 30% to 60% of the Region s population does not achieve even the minimum recommended levels of physical activity (12). For adolescents, this lack of physical activity is particularly disturbing as the development of healthy habits is formed at this stage and tends to stay throughout life (13). As occupations shift from manual labor and agriculture to the service sector, physical activity levels have declined (13). This has been driven by increased urbanization and motorized transportation, urban zoning policies that promote car-dependent suburbs, lack of attention to needs of pedestrians and cyclists in urban planning, the ubiquitous presence of labor-saving

7 Page 7 devices in domestic life, and the growing use of computers at work and for entertainment (12). 15. Tobacco consumption is the leading cause of avoidable death in the Americas. It is the cause of over one million deaths in the Region each year, with the Southern Cone having the highest mortality rate from smoking-related causes(4). Approximately onethird of all deaths from heart disease and cancer in the Americas can be attributed to tobacco consumption. In the majority of the Region s countries, more than 70% of smokers start smoking before the age of 18 (4). In a survey conducted in 2000 among the youth, the prevalence of tobacco use varied from between 14% and 21% in the Caribbean to 40% in the Southern Cone (4). Among the youth, 23% and 25% from the United States (14) and Canada (15) respectively, reported using tobacco products in In addition to these modifiable risk factors, inadequate access to quality health services, including clinical prevention and diagnostic services, along with difficult access to essential medicines are significant factors which contribute to the burden of chronic diseases. The poor often face several health care barriers including the inability to afford user charges for health care, financial barriers for necessary prescription drugs, and lack of transportation to reach health services. In addition, vulnerable populations may face communication barriers, inhibiting the benefits of services. 17. For the purposes of this Strategy, the key determinants for chronic disease are illustrated below in Figure 1. The determinants are categorized within biological and behavioral risk factors, environmental conditions, and global influences.

8 Page 8 Figure 1: Key Determinants of Chronic Diseases Chronic Diseases: Cardiovascular diseases including hypertension, cancers, diabetes, and chronic respiratory diseases Biological Risk Factors: Modifiable: overweight/obesity, high cholesterol levels, high blood sugar, high blood pressure Non-modifiable: age, sex, race, genetics Behavioral Risk Factors: Tobacco use, unhealthy diet, physical inactivity, alcohol abuse Environmental Determinants: Social, economic, political conditions, such as income, living and working conditions, physical infrastructure, environment, education, access to health services and essential medicines Global Influences: Globalization, urbanization, technology, migration Cost Effective Prevention and Management Practices 18. There is a strong evidence-base for the cost-effectiveness of disease prevention and early detection interventions. Cardiovascular diseases, some cancers and diabetes can be prevented or delayed by: changes in diet and lifestyle, screening for risk or for early manifestation of disease, treatment of precursor lesions or earlier treatment of disease, and pharmacological interventions (16). 19. Routine preventive health exams in primary care settings are a recommended approach for chronic disease prevention (17). The essential assessments include: blood pressure measures; calculation of body-mass index; lipid profile; blood glucose testing; for women, screening for cervical cancer (Pap test) and for breast cancer (clinical breast exam and mammography); and screening for colorectal cancer. In addition, the current

9 Page 9 evidence suggests that opportunistic screening should be conducted to detect prediabetes in overweight individuals aged 45 years or older. 20. For those already diagnosed with a chronic condition, cost-effective treatments are available. For example, medications such as beta blockers and aspirin are low-cost and effective measures to reduce the chance of recurrence of heart attacks. For people with diabetes, interventions include controlling blood sugar, ensuring access to insulin for people requiring it, blood pressure control (with or without medication), and foot care for the prevention of amputations. For cancer control, treatment is cost-effective for cervical, breast, oral, and colorectal cancers and includes surgical removal of tumors, chemotherapy, and radiation therapy (16). 21. WHO conducted a regional review of the cost-effectiveness of chronic disease interventions in the Americas-B region. The most cost-effective strategies were those that were population-based, and included increasing tobacco taxes to the highest regional tax rate of 75% (1). The average cost effectiveness (ACE) for this intervention was $19. Legislation to decrease salt content in processed foods, plus appropriate labeling and enforcement, and legislation and health education to reduce cholesterol were also cost effective with an ACE of $127 and $135 respectively. The least cost-effective were interventions directed to individuals, such as nicotine replacement therapy with an ACE of $3,083, and the provision of statins and education on lifestyle modification delivered by physicians to patients whose cholesterol concentrations exceeded 220mg/dl with an ACE of $1,326 (2). 22. Environmental and multisectoral interventions are effective. For example, it has been demonstrated that replacing the 2% of energy that comes from transfat with polyunsaturated fat would reduce cardiovascular diseases (CVD) by 7% to 40% and would also reduce type 2 diabetes (16). Because transfat could be eliminated or significantly reduced by voluntary industry action, the cost amounts to no more than $0.50 per person per year (16). Legislation that mandates reduced salt content in manufactured foods is also cost effective and when accompanied by an education campaign can reduce blood pressure at a cost of $6.00 per year (16). Guiding Principles 23. This Regional Strategy and Action Plan is based on PAHO s commitment to contextualize strategies and goals taking into consideration on the health priorities and the unique social, economic, and political conditions of. It also considers the following: All of LAC and the Caribbean with the exception of Bolivia, Canada, Cuba, Ecuador, Guatemala, Haiti, Nicaragua, Peru, and the United States of America.

10 Page 10 PAHO s Strategic Framework for health promotion, primary health care, social protection, and human rights. The Framework for the Technical Cooperation Strategy of addressing the unfinished agenda, protecting achievements, and facing new challenges. The Managerial Strategy for the Work of the Pan American Sanitary Bureau by using a country-focused approach and targeting special population groups. Framework for Action 24. The Strategy incorporates some of the concepts and themes from the following WHO and PAHO resolutions: the WHO Global Strategy for the Prevention and Control of Chronic Diseases (WHA53.17, 2000); Cardiovascular Disease, especially Hypertension (CD42.R9, 2000); A Public Health Response to Chronic Diseases (CSP26/15, 2002); Framework Convention for Tobacco Control (WHA56.1, 2003); Global Strategy on Diet, Physical Activity, and Health (WHA57.17, 2004); and Cancer Prevention and Control (WHA58.22, 2005). In addition, this Regional Strategy is consistent with the obesity prevention strategies laid out in the International Obesity Task Force (19). It will also consider the new regional and global initiatives that are being developed, such as the Regional Strategy on Nutrition and Development. 25. The life course perspective is considered in this Strategy and recognizes the environmental, economic and social factors, and the consequential behavioral, and biological processes that act across all stages of life to affect disease risk (20, 21). The main factors during different life stages include the following: fetal stage: slow fetal growth, poor maternal nutritional status, and low socioeconomic position at birth; infancy and childhood: lack of breast-feeding, inadequate growth rate, inadequate diet, lack of physical activity, low socioeconomic position, and poor education of the mother; adolescence: inadequate diet such as low intake of fruits and vegetables and high-energy intake, physical inactivity, and tobacco and alcohol use; adult: behavioral risk factors such as high saturated-fat intake, elevated salt consumption, reduced fruit and vegetable intake, tobacco and alcohol use, lack of physical activity, and related biological risk factors. 26. The recognition of risk factors acting at all stages of life and affected by socioeconomic circumstances warrants reorientation of policies and programs (20). It

11 Page 11 calls for the need to prioritize the poorest populations and vulnerable groups. It also indicates the need to direct preventive interventions to youth, inasmuch as lifestyle habits are established during childhood and adolescence. Preventive interventions are also required early in development, particularly during the prenatal period, to ensure healthy fetal development and infancy and to reduce risk of later onset of chronic diseases (20). 27. Intersectoral collaboration needs to be developed with sectors outside the health sector in order to achieve an impact on chronic diseases. In this regard, collaboration is needed with the education, communication, agriculture, transportation, economic, and trade sectors. Strategic Approaches Advocacy for policy changes and development of effective public policy 28. This Strategy will encourage and provide technical cooperation for the establishment of sound and explicit public policies that support better health status and a life free of chronic disease-related disability. The policies will be based on WHO resolutions and recommendations, particularly in relation to the Framework Convention on Tobacco Control; the Global Strategy on Diet, Physical Activity, and Health; and the Global Strategy for Infant and Young Child Feeding. Policies will address the broad social, economic, and political determinants of health and reflect the values of equity, excellence, social justice, respect, gender equality, and integrity. Advocacy will be utilized to advance policy and institutional changes that will support chronic disease programs. It will emphasize the key role of governmental functions and empower the health sector to engage other sectors in collaborative actions to ensure that chronic disease issues are collectively addressed. Build capacity for community-based actions 29. Behavioral change is not based solely on individual decisions; rather it is influenced largely by environmental factors such as social norms, regulations, institutional policies, and the physical environment. Public health strategies therefore need to include community-based actions that influence changes within communities and within settings, promote healthy lifestyles and help prevent obesity. 30. This strategy will focus on community interventions that build supportive environments for risk-factor reduction, mobilize communities to change institutional policies, and to become active participants in the creation of enabling environments. It will also focus on healthy workplace and school settings. Interventions will be channeled through PAHO s CARMEN, an international network that shares the common goal of increasing technical capacity among to reduce risk factors associated with

12 Page 12 chronic diseases through integrated, community-based preventive approaches; and through PAHO s initiatives on healthy settings and health-promoting schools. These interventions will adhere to WHO s Global Strategy for the Prevention and Control of Chronic Diseases and the Global Strategy on Diet, Physical Activity, and Health. Strengthen health services for integrated prevention and management of chronic diseases 31. This Strategy recognizes that prevention and control of chronic diseases require long-term patient contact with accessible primary-health-care services, which are based on high standards of care and best practices. Integrated prevention involves interventions that simultaneously prevent and reduce a set of common modifiable risk factors. In addition, the management of chronic diseases requires integration of services through strengthened referrals and relationships among primary, secondary, and tertiary levels of care. Appropriate management should also cover prevention, screening and early detection, diagnosis, treatment, rehabilitation, and palliative care. This includes access to quality health services, including diagnostic services and access to essential medicines. Innovative models will be developed and tested for quality of care of chronic diseases. 32. The strategy will include the development, testing, and dissemination of effective chronic disease management approaches, guidelines, and tools. Interventions will be based on the WHO recommendations in reports, such as Preventing Chronic Diseases: a Vital Investment, and Innovative Care for Chronic Conditions: Building Blocks for Action, as well as the resolution on cancer prevention and control. Reinforce the competencies of the health-care workforce for chronic disease prevention and management 33. Health care providers are instrumental in improving health and preventing and managing chronic diseases in individuals. To provide effective care for chronic conditions, multidisciplinary health teams with an appropriate skill mix are required. The skills of health professionals must be expanded so that they can tackle the complexities of chronic conditions with a team approach. Curricula for health professionals should address the issues of prevention and management of chronic diseases and develop the appropriate abilities. This strategy considers the importance of continuing education for the health care work force to reinforce competencies for patient-centered care, partnering with patients and with other providers, using continuous quality-improvement methods, effectively using information and communications technology, and adopting a public health perspective. Create Multisectoral Partnerships and Networks for Chronic Disease

13 Page The successful implementation of chronic disease policies and programs requires the concerted efforts of multiple partners and stakeholders from the social service, public and private, and health-related sectors such as the agricultural, economic, public works, trade, transportation, and parks and recreation. Furthermore, it requires action at the various levels of governmental and nongovernmental agencies, including international and multilateral organizations, and regional, subregional, national, and municipal organizations. Professional associations, academic institutions, civil society, patients groups, and people affected by chronic diseases also have key roles to play in influencing chronic disease policies and programs. This strategy will facilitate dialogue and build partnerships among these key multisectoral stakeholders in order to advance the chronic disease agenda and to ensure stakeholder involvement in establishing policies and programs. The Strategy will also include working through existing regional networks such as CARMEN and the Physical Activity Network of the Americas (PANA). Build Capacity for Chronic Disease Information Generation and Knowledge Management 35. Timely and accurate information on risk factors, chronic disease occurrence, distribution, and trends is essential for policy-making, program planning, and evaluation. Therefore, this strategy will build capacity in countries to incorporate chronic disease surveillance into the public health system and will utilize surveillance information for program development and policy formulation. The strategy will encourage integration among the multiple data sources in order to access the complete range of information to determine the status of chronic diseases. Information will be analyzed, synthesized, and disseminated at the country, subregional, and regional levels. Improvements are needed with the current mechanisms for systematic surveillance and for tracking the trends of chronic diseases and their risk factors at the national and subregional levels. In addition, information on new and emerging knowledge for effective interventions for noncommunicable disease prevention and control will be gathered and disseminated.

14 Page 14 Plan of Action Goal 36. To prevent and reduce the burden of chronic diseases and related risk factors in the Americas. 37. A detailed Plan of Action is included in the Annex. Lines of Action Public Policy and Advocacy 38. Objective: To ensure and promote the development and implementation of effective, integrated, sustainable, and evidence-based public policies on chronic disease, their risk factors, and determinants. 39. In various countries, several policies, laws, and regulations adopted have been successful in preventing or reducing the burden of disease and injury, such as tobacco taxation and the use of seat belts and helmets. Yet, as the 2005 national capacity assessment for chronic disease prevention and control revealed, a substantial proportion of countries in LAC have no policies or plans to combat chronic diseases. Developing a systematic process for policy formulation continues to be the primary challenge in combating chronic diseases and their risk factors. 40. The development of a unified, systematic framework for public policy is the first step in battling this epidemic. Defining policy priorities, establishing mechanisms for assessment and evaluation, engaging all sectors of society, and inter-country technical cooperation is also imperative to this action plan. Surveillance 41. Objective: To encourage and support the development and strengthening of countries capacity for better surveillance of chronic diseases, their consequences, their risk factors, and the impact of public health interventions. 42. Throughout the Region there are inadequacies and varying capacities for chronic disease surveillance. Most of the countries have limited resources to conduct chronic disease surveillance. In response to this paucity, PAHO has set an objective within this action plan to strengthen and/or expand established chronic disease surveillance systems in.

15 Page To meet the differing needs of each country, this plan focuses on strengthening the following capacities in the countries: ongoing systematic collection of reliable, comparable, and quality data; timely and advanced analysis; dissemination and use of analysis results for national policy and program planning and evaluation; technical competency of the surveillance work force; and novel thinking and innovation. An established surveillance system will facilitate monitoring the progress of this Regional Strategy. Health Promotion and Disease Prevention 44. Objective: To promote social and economic conditions that address the determinants of chronic diseases and empower people to increase control over their health and adopt healthy behaviors. 45. Health promotion is an essential part of an integrated approach for chronic disease prevention and control. This strategy incorporates some of the concepts and themes from Health Promotion: Achievements and Lessons Learned from Ottawa to Bangkok (Document CE138/16). The strategy supports the Ottawa Charter s call to prioritize health promotion and empower individuals and communities to exercise greater control over their health status and social determinants. To address the needs for health promotion, particularly to promote healthy diets, physical activity and tobacco control, this plan proposes the following: the promotion and adoption of healthy dietary habits, active lifestyles, and the control of obesity and nutrition-related chronic diseases; the development of public policies, guidelines, institutional changes, communication strategies, and research related to diet and physical activity; health promotion and disease prevention strategies; a life course perspective that considers health starting with fetal development and continuing into old age; and the concerted effort of multiple partners from the health and health-related sectors. Integrated Management of Chronic Diseases and Risk Factors 46. Objective: To facilitate and support the strengthening of the capacity and competencies of the health system for the integrated management of chronic diseases and their risk factors. 47. The current acute health care model has not proven effective in dealing with prevention and management of chronic conditions. Successful chronic disease programs require an intersectoral approach and a reorientation of the health care system. It is

16 Page 16 necessary to improve the accessibility and availability of services and access to essential medicines and to have multidisciplinary health teams with the appropriate skill mix delivering services. Emphasis is needed on quality of care to reduce barriers related to social, economic, and cultural factors and to improve social protection for health, particularly among vulnerable populations. 48. In order to face these challenges, this action plan considers that prevention and management of chronic diseases requires integration through strengthened referrals and relationships among primary, secondary, and tertiary levels of care. The entire spectrum of disease management from prevention to screening and early detection, diagnosis, treatment, rehabilitation, and palliative care is necessary. The constructs of the Chronic Care Model are incorporated into the objective for the management of chronic diseases and risk factors, and are aimed at improving outcomes in five areas (21). These areas are as follows: a coherent approach to system improvement, development and adherence to guidelines, self-management support for people with chronic diseases, improved clinical information systems, and appropriate skill mix and improved technical competency of the health work force, including cultural competence and sensitivity. This plan also considers technical assistance for chronic disease programs, the reorientation of health services towards chronic diseases, and improved access to essential medicines and technologies. 49. This Strategy recognizes the call for a renewed approach to primary health care and the highest attainable level of health for everyone as emphasized in the Regional Declaration on the New Orientations for Primary Health Care (promulgated at the 46th Directing Council). Also reflected in this plan is Resolution CD45.R7 which prioritizes access to medicine and other health supplies. Budget for the Regional Strategy 50. The estimated budget for the implementation of this Regional Strategy and Plan of Action is approximately $13 million per year. The Unit of Noncommunicable Diseases needs to mobilize resources to move its current annual budget of $1.1 million to an annual budget of $4.1 million. In the related technical units of PAHO (i.e. Healthy Settings, Risk Assessment and Management, Health Services Organization, Health Policies and Systems, and Essential Medicines, Vaccines, and Health Technology), resource mobilization is needed to increase their budget from the current annual budget of $7.8 million to $9.8 million. 51. Following the completion of the Country Cooperation Strategy (CCS), several countries have identified the noncommunicable chronic diseases burden and have increased their national resources, as well as have assigned a priority level in the technical cooperation needs assessment. PAHO country advisors with specific skills for chronic disease management are presently situated in Barbados, Chile, Costa Rica,

17 Page 17 Jamaica, as well as in the Caribbean Epidemiology Center (CAREC) and Caribbean Food and Nutrition Institute (CFNI). Action by the Executive Committee 52. The Directing Council is requested to consider the annexed resolution proposed by the Executive Committee. References Annexes

18 Page 18 REFERENCES 1. World Health Organization. WHO Global Report. Preventing Chronic Diseases A Vital Investment. Geneva: WHO; Yach D, Hawkes C, Gould CL, Hofman KJ. The Global Burden of Chronic Diseases. JAMA 2004; 291(21): World Health Organization. The World Health Report Reducing Risks, Promoting Healthy Life, Geneva: WHO; Pan American Health Organization. Health in the Americas. Volume I ed. Washington, DC: PAHO; Murray C, Lopez AD. The global burden of disease. Cambridge, Mass, USA: World Health Organization, Harvard School of Public Health and World Bank, Velazquez-Monroy O, Rosas Peralta M, Lara Esqueda A, Pastelin Hernandez G, Sanchez-Castillo C, Attie F, et al. Prevalence and interrelations of noncommunicable chronic diseases and cardiovascular risk factors in Mexico. Final outcomes from the National Health Survey. Archivos de cardiología de México 2003;73(1): World Health Organization and International Union against Cancer. Global Action against Cancer Updated Version. Geneva: WHO; Barceló A, Aedo C, Rajpathak S, Robles S. The cost of diabetes in Latin America and the Caribbean. Bulletin of the World Health Organization 2003;81(1): Pan American Health Organization. The WHO Global Strategy on Diet, Physical Activity, and Health (DPAS), Implementation Plan for Latin America and the Caribbean (Unpublished document). 10. Klein-Geltink J, Choi B, Fry R. Multiple exposures to smoking, alcohol, physical inactivity and overweight: Prevalences according to the Canadian Community Health Survey Cycle 1.1. Chronic Diseases in Canada 2006; 27 (1): National Center for Health Statistics. National Health and Nutrition Examination Survey. Accessed 26 May 2006.

19 Page World Health Organization. Sedentary lifestyle: A Global Public Health Problem. Geneva: WHO; World Health Organization. Diet, Nutrition and the Prevention of Chronic Disease, Report of a Joint WHO/FAO Expert Consultation, Geneva: WHO; (WHO Technical Report Series No. 916). 14. Tobacco Control Programme, Health Canada. Youth Smoking Survey Accessed 30 May Global Youth Tobacco Survey Collaborative Group. Special Report: Tobacco use among youth: a cross country comparison. Tobacco Control 2002;11: Jamison, DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al., eds. Priorities in Health. Washington, DC: The World Bank; US Preventive Services Task Force. Guide to Clinical Preventive Services. 3 rd ed. Washington, DC: Agency for Health Care Research and Quality; Eyre H, Kahn R, Robertson RM; American Cancer Society, the American Diabetes Association, and the American Heart Association. Collaborative Writing Committee. Preventing Cancer, Cardiovascular Disease and Diabetes: a common agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association. Diabetes Care 2004;27(7): Swinburn, B, Gill, T, Kumanyika, S. Obesity Prevention: a proposed framework for translating evidence into action. Obesity Reviews: an Official Journal of the International Association for the Study of Obesity 2005;6(1): Aboderin, I, Kalache, A, Ben-Sholmo, Y, Lynch, JW, Yajnik, CS, Kuh, D, et al. Life Course Perspectives on Coronary Heart Disease, Stroke and Diabetes: Key Issues and Implications for Policy and Research. Summary report of a meeting of experts 2-4 May Geneva: WHO; (WHO/NMH/NPH/01.4) 21. Wagner EH, Glasgow RE, Davis C, Bonomi AE, Provost L, McCulloch D, et al. Quality Improvement in Chronic Illness. A Collaborative Approach. The Joint Commission Journal on Quality Improvement 2001;27(2):63-80.

20 PLAN OF ACTION FOR THE INTEGRATED PREVENTION AND CONTROL OF CHRONIC DISEASES AND RISK FACTORS POLICY Objective: To ensure and promote the development and implementation of effective, integrated, sustainable, and evidence-based public policies on chronic disease and their risk factors (RF) and determinants. Specific Objectives Indicators Activities 1. To strengthen public policy development and implementation processes through the application of a systematic framework with the following core functions: (1) surveillance and advocacy for action, (2) formulation and adoption of policy, and (3) appropriate implementation of policy based on local consideration and needs. 2. To identify and define policy priorities at the country and regional levels for chronic disease and their risk factors and determinants. By 2007, PAHO/WHO and relevant stakeholders have developed a prototype of a systematic framework for chronic disease public policy. By 2007, PAHO/WHO and relevant stakeholders have developed a process of technical collaboration to assist at least 6 to implement components of a framework for public policy. By 2008, at least 10 are using the framework to create public policies. By 2010, all have policies to support noncommunicable disease (NCD) programs. By 2010, 70% of have established a multisector policy advisory group to define priorities and to support public policy development processes. By 2010, PAHO/WHO and relevant stakeholders have convened subregional and regional consultations to define common policy priorities at subregional and national levels. Conduct workshops to create a framework for NCD policy with. Conduct workshops to analyze current situation related to NCDs Conduct studies to estimate the current situation related to NCDs. Conduct studies to estimate the cost for chronic diseases. Establish focal point for policy development process. Create the NCD national program. Convene interdisciplinary advisory group. Organize national committee to review evidence and lessons learned. Hold working sessions to plan policies and make them official. Develop a national strategic plan for prioritizing policies, planning policies, and making policies official. Provide systematic process for identifying policy priorities. Conduct meetings of stakeholders to define priority policies for chronic diseases. Convene advisory group to identify policy priorities for tobacco control, physical activity, diet, alcohol control, health services, access to pharmaceutical products, and healthy settings. Annex A

21 Specific Objectives Indicators Activities 3. To engage all sectors and civil society in influencing policy- and decision-making processes, including advocacy for the prevention and control of chronic disease in the Region. 4. To establish a regional mechanism for the systematic assessment and monitoring of countryspecific public policies that address chronic diseases, and the development of methodologies for their use in different countries. By 2008, 70% of have established institutional mechanisms for the development of national alliances. By 2008, 70% of have cultivated an environment for the development of a national alliance among sectors of civil society interested in chronic disease prevention and control. By 2010, members of the national alliance are visible as a strong partner in the processes of formulation, implementation, and evaluation of chronic disease public policy. By 2008, a formalized observatory for policy and action assessment and analysis is operational in the Americas with methodologies and tools for policy analysis. By 2010, at least 3 new have established a core technical capacity to engage in systematic policy analysis in chronic diseases. By 2010, PAHO and participating countries have produced chronic disease policy reviews and progress reports. Create campaign to establish alliances among multidisciplinary sectors Conduct meetings to advocate for chronic disease prevention and control with potential members of the alliance. Conduct multisectoral meetings to establish alliances with multiple sectors. Advocate prioritizing chronic disease policy on the agendas of Ministries of Health. Create campaign to promote the Regional Strategy and Plan of Action. Establish a steering committee to formalize a regional policy observatory. Create a methodology for monitoring and evaluating the development of chronic disease policies and their implementation. Conduct 1 regional and 5 subregional workshops to support the development of country capacity to engage in chronic disease policy analysis. Establish a working group for the development of systematic assessment and monitoring of chronic disease policy. Convene working group for the development of the policy and action observatory with municipalities and other sectors. Produce and publish annually the results of the Policy Observatory. Annex A - 2 -

22 Specific Objectives Indicators Activities 5. To encourage intersectoral cooperation within and between countries and to establish mechanisms for sharing best practices on the development and implementation of effective public policies. By 2010, PAHO, in collaboration with policy observatory participating countries, will disseminate policy review reports from. By 2010, a mass communication strategy is established in 70% of to disseminate information to interested parties and the public at large. By 2010, with relevant stakeholders will have established a national forum for public policy dialogue on chronic diseases and review of policy analysis reports and best practices. Create a methodology for a national forum. Create a methodology for subregional cooperation between countries. Develop and maintain a web-based clearinghouse for lessons and evidence from annual policy review reports and analyses. Produce and publish an annual regional profile on best practices for effective public policy development and implementation in the Region. Create a national forum for public policy dialogue. Publish reports to disseminate and promote the use of evidence from the policy observatory at national, subnational, and local levels. Develop a proposal for governments to adopt legislation in support of health promotion, such as tobacco control legislation consistent with the WHO Framework Convention on Tobacco Control (FCTC) Annex A

23 SURVEILLANCE Objective: To encourage and support the development and the strengthening of countries capacity for better surveillance of chronic diseases, their consequences, their risk factors, and the impact of public health interventions as part of the integrated strategy on NCD prevention and control. Specific Objectives Indicators Activities 1. To encourage the development and strengthening of chronic disease surveillance systems which are ongoing, systematic, and linked to public health actions, in order to assess the burden (e.g. mortality, morbidity, disability, and economic costs) of chronic diseases, their trends, related risk factors (e.g. tobacco use, unhealthy diet, physical inactivity, and alcohol abuse), social determinants (e.g. social, economic, and political conditions), and public health interventions (e.g. health services utilization). By 2010, 75% of have defined indicators for national surveillance related to chronic diseases (NCD), associated risk factors, and public health interventions, within their national basic data; 95% by 2015 By 2010, 50% of have established a surveillance system for NCD, risk factors, and public health interventions, as part of their national public health surveillance system; 75% by By 2010, 50% of have collected population-based information on major chronic diseases, diet, physical activity, tobacco use, alcohol consumption, and preventive health services use; 75% by In collaboration with and regional centers, provide a situational analysis to assess country surveillance capacity and status in order to evaluate and refine target percentages for all indicators. Establish guidelines/templates for development and evaluation of each level of surveillance system. Provide recommendations and technical assistance on chronic disease surveillance (studies, training, workshops, technical cooperation among countries) to PAHO priority countries, on a targeted or on-request basis. Assist countries with the development and implementation of national surveillance systems. Provide support to countries with lesser capacity to develop surveillance systems. Systematize best tools and practices in order to standardize and regionalize surveillance. Produce ongoing situational analysis for surveillance, prevention, and control of chronic diseases (every 5 years). In collaboration with, develop a regional resource mobilization plan. Coordinate and assist with resource mobilization efforts in order to obtain funds to enable implementation of surveillance systems. Coordinate regional transfer of successful experience and lessons learned in surveillance among Member States. Define indicators for chronic disease national surveillance, including RF and public health interventions. Include surveillance of NCD, RF, and public health interventions as an essential component of national chronic disease prevention and control programs. Annex A - 4 -

24 2. To improve multipartner collaboration to mobilize community, national, subregional, and regional partnerships to stimulate the effective development of surveillance systems and utilization of information. By 2010, a regional discussion forum for NCD surveillance has been established that involves 75% of ; 95% by By 2010, 75% of have established a national coordinating committee with partners such as governments, NGOs, academia, professional networks, industries, experts, and the general public; 95% by Utilize and modify as necessary the recommended surveillance guidelines/tools. Collect population-based information on major chronic diseases, diet, physical activity, tobacco use, alcohol consumption and preventive health service use. Assist the in the preparation of a regional situational analysis. Assist the in the preparation of surveillance guidelines/tools. Assist the in conducting studies and training workshops. Develop national resource mobilization plans. Assist the in coordinating regional efforts in enhancing country surveillance capacities. In collaboration with and regional centers, identify regional and subregional priorities. Conduct a regional stakeholder analysis to identify the stakeholders and partners for collaboration (governments, nongovernmental organizations (NGOs), academia, professional networks, industries, experts, and the general public). Provide results of the stakeholder analysis to Member States to assist in their formation of national coordinating committees. Monitor progress of formation of national coordinating committees to decide on the best time to establish a Regional Discussion Forum. Provide terms of reference for a Regional Discussion Forum. Convene consultations among all relevant stakeholders, including to set up a Forum.. In collaboration with, identify key stakeholders and universities that can serve as WHO Collaborating Centers for chronic disease surveillance. Develop continuous quality improvement methods that will enhance the quality of surveillance systems. Identify country stakeholders and partners for Annex A